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Contact Lenses > ocular response to CL wear > Flashcards

ocular response to CL wear Flashcards

1
Q

what is the most important thing to do when monitoring a patient with their contact lens aftercare

A

record keeping

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2
Q

list the 5 reasons for why record keeping is so important

A
  • monitoring progression
  • record across time, within and between practitioners
  • impact new therapies or management
  • medico-legal requirements
  • patient communication
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3
Q

what type of language does a standardised grading scale use

A

it uses a common language, which can be interpreted as the same by everyone

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4
Q

why is a common language used by a standardised grading scale

A

it reduces intra/inter observer variability

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5
Q

name an advantage to the CCLRU grading scale

A

it uses real eyes

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6
Q

list 2 disadvantages to the CCLRU grading scale

A

uses:

  • different eyes
  • different illumination
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7
Q

list 2 advantages to the efron grading scale

A
  • illustrates the precise severity

- image constancy

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8
Q

name an advantage to the efron grading scale

A

does not use real eyes

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9
Q

list the three reasons for having a legal document, in the form of a patient record

A
  • an accurate record of presenting sings and symptoms
  • respond to complaints
  • proof that standard of care was met: if its not written, it means its not done
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10
Q

list the three different ways of range/steps of a grading scale

A
  • 1-4
  • 0-5
  • decimal scale
  • +/- sign

(from non-severe, to very severe)

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11
Q

what is the severity of a grade 0

A

normal

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12
Q

what is the clinical interpretation of a grade 0

A

no action required

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13
Q

what is the severity of a grade 1

A

trace

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14
Q

what is the clinical interpretation of a grade 1

A

action rarely required

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15
Q

what is the severity of a grade 2

A

mild

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16
Q

what is the clinical interpretation of a grade 2

A

action possibly required

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17
Q

what is the severity of a grade 3

A

moderate

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18
Q

what is the clinical interpretation of a grade 3

A

action usually required

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19
Q

what is the severity of a grade 4

A

severe

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20
Q

what is the clinical interpretation of a grade 4

A

action required

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21
Q

list 4 things to look for during the slit lamp routine a CL aftercare

A
  • palpebral conjunctiva
  • corneal staining
  • CL deposits
  • any CL adverse events
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22
Q

how many areas is the palpebral conjunctiva divided into, and name the areas which are the most relevant for CL wear

A

5 areas

areas 1,2,3 are most important for CL wear (in the vertical middle area)

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23
Q

which areas of the conjunctiva generally has more bumps, and what is its importance

A

areas 5 and 4 tend to have more bumps, but as its in the peripheral conjunctiva with least contact with the CL, it is not as important as areas 1, 2 and 3

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24
Q

what aspect of the conjunctiva are you grading when observing with the slit lamp

A

the redness and roughness, of the tissue underneath the eyelid

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25
Q

what symptom does a bumpy/rough eyelid cause with a CL patient

A

when the patient blinks, the CL will move with the eyelid as it grips onto the roughness

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26
Q

what two things can possibly cause a red and rough palpebral conjunctiva

A
  • hay fever season

- sleeping in CL’s

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27
Q

what does the effort scale tell you about a corneal staining

A

of micropunctate (the little dots seen on the cornea)

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28
Q

what 2 things does the efron scale not tell you about corneal staining

A

it does not tell you about:

  • the foreign body type
  • the mechanical type (SEAL)
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29
Q

what three things does the CCLRU scale tell you about the corneal staining

A
  • type
  • extent (area covered)
  • depth
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30
Q

how many areas does the CCLRU scale split the cornea in and tell you about with staining

A

5 areas

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31
Q

what filter is best used with observing corneal staining and state 2 reasons why

A 
use the yellow filter 
because:
- you can see the staining much clearer 
and 
- without flourescein
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32
Q

how do you set up the slit lamp to investigate the depth of the corneal staining and what does this help with

A

use a wide angle

helps to distinguish between whether its an epithelial staining or a stromal staining

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33
Q

as well as writing the type, extent and depth of the corneal staining, what else is important to write in your record card about corneal staining

A

which scale you used to grade it with

and don’t guess the scale, always look it up when measuring the corneal staining

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34
Q

what is grade 1 or more of corneal staining regarded as

A

clinically significant

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35
Q

what grade of corneal staining, requires a management plan

A

grade 3 or more

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36
Q

in how many CL patients can corneal staining be insignificant (0.5-1) and asymptomatic

A

60%

where the severity signs are not related to the symptoms

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37
Q

why do 35% of non CL wearers get corneal staining

A

due to incomplete blink or closure

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38
Q

list the 5 types of corneal staining

A
  • desiccation ‘smile’
  • foreign body ‘linear’
  • mechanical ‘SEAL’
  • desiccation ‘3 and 9 o’clock’
  • toxicity ‘diffuse’
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39
Q

what type of corneal staining does an incomplete blink cause

A

desiccation ‘smile’ staining

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40
Q

what causes a foreign body linear, corneal staining

A

caused by blinking whilst something is stuck underneath the eye and is scraping over the cornea, hence ‘linear’

41
Q

what does SEAL stand for in a mechanical corneal staining and what is it caused by

A

superior arcuate epithelial lesion

a stiffer material of a silicone hydrogel material SCL

42
Q

what type of corneal staining does a RGP CL cause

A

desiccation 3 and 9 o’clock corneal staining (caused by RGP and not SCL, because RGP lenses are smaller)

43
Q

what can an toxicity staining be caused by

A

CL cleaner or allergy response to solution

44
Q

what 2 types of CL deposits is formed as hydrophobic spots on the lens with mucous or calcium

A
  • calculi

- jelly bumps

45
Q

which type of contact lens is calculi lens deposits most commonly found on

A

monthly, FDA group 2, high water non-ionic hydrogel lenses

46
Q

why are calculi lens deposits not found on daily hydrogel lenses

A

because the calcium deposits take time to develop

47
Q

what do calculi look like as seen with an optic section with the slit lamp

A

raised bumps sitting on the front, but not embedded in the CL

48
Q

what are jelly bumps formed on a contact lens caused by

A

the amount of mucous on the tear film and the quality of the tears

49
Q

what type of contact lens is jelly bumps and calculi lens deposits most commonly found with

A

FDA group 2, high water, non-ionic hydrogel lenses

50
Q

what is the appearance of a lipid coating on the contact lens

A

the tear film has a coloured fringe and only if the lipid is fat and not oil
lipid appears fatty and greyish

51
Q

what 2 types of contact lenses is a lipid coating most commonly found with

A
  • FDA group 2, high water, non-ionic hydrogel

- silicone hydrogel

52
Q

what does a protein film on the contact lens look like

A

a dirty tear film which is not clear and looks oily

53
Q

what type of contact lens is a protein film most commonly found with

A

FDA group 4, high water, ionic hydrogel

54
Q

list the two types of non-significant, asymptomatic CL adverse events

A
  • asymptomatic infiltrative keratitis AIK

- asymptomatic infiltrates AI

55
Q

list the 4 types of significant, mostly symptomatic CL adverse events

A
  • superior epithelial arcuate lesion SEAL
  • contact lens associated papillary conjunctivitis CLPC
  • contact lens acute red eye CLARE
  • contact lens peripheral ulcer CLPU
56
Q

name a serious CL adverse event

A

microbial keratitis MK

57
Q

what are the signs of a asymptomatic infiltrative keratitis AIK

A
  • sterile corneal infiltrates
  • inflammatory cells from limbal blood vessels which form white spots on the cornea (close to the limbus)
  • limbal injection: BV’s are dilated
58
Q

what 5 things is a asymptomatic infiltrative keratitis AIK, as response to

A
  • hypoxia
  • bacteria (e.g. in lens solution)
  • lens deposits (so lens needs to be changed)
  • allergic reaction
  • poor hygiene
59
Q

what 3 things will you do to manage someone with a asymptomatic infiltrative keratitis AIK

A
  • temporary discontinuation of lens wearing
  • careful monitoring (so doesn’t become worse, ask px to come back after a week and not wear lenses during that week)
  • ocular lubricants and cold compresses (is theres a gritty sensation, use sterile water and never tap water, especially if its a non-sterile infiltrates as that can result in microbial keratitis)
60
Q

what is the appearance of asymptomatic infiltrates AI

A
  • little white dots close to the limbus
  • no redness
  • smaller infiltrates than asymptomatic infiltrative keratitis AIK
  • milder than AIK

need high mag on slit lamp to spot the infiltrates and swing the light to catch a view of it

61
Q

what is the aetiology of asymptomatic infiltrates AI (5 things)

A

same as asymptomatic infiltrative keratitis AIK:

  • hypoxia
  • bacteria (e.g. in lens solution)
  • lens deposits (so lens needs to be changed)
  • allergic reaction
  • poor hygiene
62
Q

how will you manage someone with asymptomatic infiltrates AI

A

same as asymptomatic infiltrative keratitis AIK:

  • temporary discontinuation of lens wearing
  • careful monitoring (so doesn’t become worse, ask px to come back after a week and not wear lenses during that week)
  • ocular lubricants and cold compresses (is theres a gritty sensation, use sterile water and never tap water, especially if its a non-sterile infiltrates as that can result in microbial keratitis)
63
Q

what is a description of a SEAL

A

mechanical pressure due to lens design or material

64
Q

where is the staining found with SEAL

A

arcuate staining parallel to the superior limbus, usually unilateral and asymmetrical

65
Q

how symptomatic is a SEAL

A

mildly symptomatic: can feel the lens, but not the staining as the lens covers it and acts as a bandage

66
Q

what 4 things will you do to manage someone with a SEAL

A
  • remove lens
  • cease CL wear for x days (depends on severity) avg 2-7 days
  • issue lubricants
  • review lens fit
67
Q

what two things can you change with a lens for a px who has a SEAL

A
  • use thinner, more flexible lens material (esp in periphery)
  • change the back surface geometry on the CL (but not always able to change)
68
Q

what will a px complain of with a contact lens associated papillary conjunctivitis

A

can feel lens all the time

69
Q

why is giant papillary conjunctivitis seen in a CL clinic more

A

because the patient can feel the CL a lot more, so can notice the symptoms more

70
Q

what is a contact lens associated papillary conjunctivitis described as

A

conjunctival inflammatory

71
Q

what two things is a contact lens associated papillary conjunctivitis a response to (i.e. the aetiology)

A
  • immunological response due to hypersensitivity to lens deposits or solution (make sure lens is clean)
  • mechanical response due to lens design or modulus (use flourescein to check for staining)
72
Q

what three things will you do to manage a patient with contact lens associated papillary conjunctivitis

A
  • manage if grade is 2 or above on the scale
  • lens wear can continue if symptoms permit
  • improve lens hygiene (cleaning and wearing time modality) or change to dailies from a 2 weekly lens etc
73
Q

when will you decide to manage a patient with contact lens associated papillary conjunctivitis

A

if its a grade 2 or above on the scale

74
Q

what is the symptoms of a contact lens acute red eye CLARE

A

woken at night with painful red eye, very sudden acute

75
Q

what are the 4 signs of a contact lens acute red eye CLARE

A
  • unilateral
  • acute hyperaemia
  • diffuse infiltrate keratitis
  • possibly anterior chamber reaction: flare and cells
76
Q

what is the cause/aetiology of a contact lens acute red eye CLARE

A

an inflammatory response of the cornea and conjunctiva due to a period of eye closure with CL wear (whilst wearing the CL) e.g. sleeping in CLs

  • due to endotoxins from gram negative bacteria (especially pseudomonas)
77
Q

how severe is a contact lens acute red eye CLARE

A

self limiting

78
Q

what two things will you do to manage someone with a contact lens acute red eye CLARE

A
  • temporary discontinuation of CL wear

- careful monitoring: see after 2 days and on a weekly basis until everything is gone

79
Q

how many % of people can be asymptomatic to a contact lens peripheral ulcer and why

A

50%

because it is in the periphery, it is flat and the lens acts as a bandage

80
Q

list 4 symptoms of a contact lens peripheral ulcer

A
  • lens intolerance
  • foreign body sensation
  • lacrimation
  • photophobia

50% of px are asymptomatic

81
Q

what can reduce the symptoms of a contact lens peripheral ulcer

A

lens removal

82
Q

what are the 2 signs of a contact lens peripheral ulcer

A
  • localised hyperaemia

- sterile circular infiltrate

83
Q

what is the 4 cause/aetiology of a contact lens peripheral ulcer

A
  • bacterial contamination
  • poor hygiene
  • hypoxia
  • solution toxicity

all cause an inflammatory response to the gram positive bacteria (esp staphylococcus)

so make sure the lens is high oxygen transmissibility and no toxicity to the solution

84
Q

how severe is a contact lens peripheral ulcer

A

self limiting on removal of CL, but must to close monitoring to ensure DDx from microbial keratitis, so make sure the epithelium is closed

85
Q

what three things will you do to manage a patient with contact lens peripheral ulcer

A
  • ocular lubricants
  • lid hygiene
  • referral only in severe cases such as acute red eye or no improvements on lens removal
86
Q

how will you know that a px with contact lens peripheral ulcer has an open ulcer causing an open epithelium

A

by instilling flourescein and viewing with an optic section

if it is open the ulcer will have a bright glow to it

87
Q

what does a sterile contact lens peripheral ulcer mean

A

no bacteria or viruses can go into it

88
Q

what is it called if bacteria had gotten into the contact lens peripheral ulcer

A

non sterile

89
Q

why can someone get microbial keratitis

A

due to poor hygiene, swimming in lenses or sleeping in lenses (or if using extended/continuous wear)

90
Q

list the 7 symptoms of microbial keratitis

A
  • pain, which is moderate to severe, with an acute onset and rapid progression
  • redness
  • photophobia: may be severe
  • discharge
  • blurred vision: especially if lesion in on visual axis
  • awareness of white or yellow spot on cornea
  • usually unilateral
91
Q

list the 6 signs of a microbial keratitis

A
  • lid oedema
  • epiphora
  • discharge: mucopurulent
  • conjunctival hyperaemia and infiltration
  • corneal lesion: usually single, central or mid periphery
  • anterior chamber activity: flare, cells, hypopyon or coagulum is severe (white blood cells)
92
Q

what is the DDx of microbial keratitis

93
Q

in which type of CL is it 5x more common to get microbial keratitis in compared to daily wear lenses

A

in extended wear lenses

94
Q

how much lower is the risk of getting microbial keratitis in a RGP wearer than a daily SCL wearer

A

1/3 compared to a daily SCL wearer

95
Q

what is the aetiology of microbial keratitis

A

an infection causing a compromised cornea with epithelial break and hypoxia from invasion of:

  • bacteria esp pseudomonas
  • virus
  • fungus
  • amoebea

with excavation of the epithelium (open), bowman’s and stroma (goes all the way into the stroma). with infiltration and necrosis or tissue

96
Q

what can microbial keratitis potentially cause

97
Q

what will you do to manage a patient with microbial keratitis

A

discontinue CL wear and urgent referral to HES

98
Q

what is the incidence of microbial keratitis in CL wearers/year

A

18-24 per 10,000/year

99
Q

what is the incidence of visual loss with microbial keratitis

A

2 per 10,000

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